Instruction to Patients:

Medical Marijuana and Pain Management

1. Open up a conversation with your doctor, informing

him/her of your interest in medical marijuana and whether or
not s/he is willing to help you decide if it is beneficial for you.

2. Discuss with your doctor your desire to reduce your opioid

use and whether s/he would agree to let you try marijuana
under a protocol where, if it is effective, you will reduce your
opioids (see Pain Contract Rider: Medical Marijuana Trial).

3. If your doctor is not willing to proceed, either negotiate

(e.g. discuss relinquishing your MJ card if it doesn’t help with
pain) or ask that s/he refer you to another pain management
doctor who is open to prescribing opioids to marijuana card
holders. In a polite manner, remind your doctor that part of
his/her duty of care is that s/he not medically abandon you and
that there are pain management doctors in this state who are
open to prescribing opioids to marijuana card holders.

4. Lastly, do not be afraid to talk to your doctor about your

personal beliefs: the importance of bodily autonomy, the need
for social reform, your religious beliefs about medicinal plants,
etc.. Do so with respect, and with the goal of helping your
doctor see you as a person with feelings, values, and hopes.
 PAIN CONTRACT RIDER: MEDICAL MARIJUANA TRIAL

Dear Dr. __________________________. I have been your patient for __________ years and
currently rely upon opioids to manage my chronic pain. Under my current pain contract, I have
agreed to not use any “illicit” drugs. However, with the legalization of medical marijuana in
Oklahoma, I would like to begin a trial use of medical marijuana and ask that you allow this rider
to our pain contract.

I currently take the following opioids __________________________________ and am hoping

that with the assistance of medical marijuana, I will be able to reduce my opioid use by at least
50% within 90 days.

To that end, I would like to explore marijuana products for an initial 30 day period. If I find it
effective, I will begin to reduce my opioid use during this period. If I report back that I have
found marijuana effective for pain, my hope is that you will reduce my opioids first by 25% and
then by 50% at my appointment after that. Hence, this trial will have three stages:
1. An initial 30 day period where I can explore marijuana products to determine whether one or
another is effective for my pain.
2. A second 30 day period where I will receive 25% lower opioid doses (e.g. fewer breakthrough
pills and/or lower dosages)
3. A third 30 day period where I will receive 50% lower opioid doses (e.g. fewer breakthrough
pills and/or lower dosages)

If, after the first, second, or third periods, I find marijuana to be ineffective for pain and/or cannot
reduce my opioid doses, my urinalysis will then be negative for THC metabolites within 30 days
after we determine that the endpoint/target has not been met.

Beginning medical marijuana trial _________________ (date)

25% reduction of opioids begins _____________ (date)

50% reduction of opioids begins ________________ (date)

If unsuccessful, THC negative urinalysis by ________________(date)

Signed,

_______________________________________ _____________________ (date)

Note: if you are not able to accept this protocol, please refer me to a pain management physician
who does allow the concurrent use of opioids and marijuana.

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 SAFETY of MJ (Respiratory Effects and in Combination with Opioids)
• Cannabis for the Management of Pain: Assessment of Safety Study (COMPASS).
The Journal of Pain, 16(12), 1233-1242.
https://www.ncbi.nlm.nih.gov/pubmed/26385201

“The primary outcome consisted of serious adverse events and non-serious adverse events.
Secondary safety outcomes included pulmonary and neurocognitive function and standard
hematology, biochemistry, renal, liver, and endocrine function. Secondary efficacy parameters
included pain and other symptoms, mood, and quality of life. Two hundred and fifteen
individuals with chronic pain were recruited to the cannabis group (141 current users and 58
ex-users) and 216 controls (chronic pain but no current cannabis use) from 7 clinics across
Canada.”

• Cannabis as an adjunct to or substitute for opiates in the treatment of chronic pain.

J Psychoactive Drugs. 2012 Apr-Jun;44(2):125-33.
https://www.ncbi.nlm.nih.gov/pubmed/22880540

“When used in conjunction with opiates, cannabinoids lead to a greater cumulative relief of pain,
resulting in a reduction in the use of opiates (and associated side-effects) by patients in a clinical
setting. Additionally, cannabinoids can prevent the development of tolerance to and withdrawal
from opiates, and can even rekindle opiate analgesia after a prior dosage has become ineffective”

• Single-Dose Effect of Marihuana Smoke — Bronchial Dynamics and Respiratory-Center

Sensitivity in Normal Subjects
N Engl J Med 1973; 288:985-989
www.nejm.org/doi/full/10.1056/NEJM197305102881902

"Physiologic variables were monitored before and for 20 minutes after smoking. In the high-dose
group the heart rate increased 28 per cent. Concomitantly, airway resistance, measured in a body
plethysmograph, fell 38 per cent; the functional residual capacity remained unchanged (± 50 ml)
throughout, and specific airway conductance increased 44 per cent. Flow-volume loops showed a
45 per cent increase in flow rate at 25 per cent of vital capacity. The low-dose group showed no
increase in heart rate but significant, if lesser changes, in airways dynamics. Carbon dioxide
sensitivity, measured by rebreathing remained unchanged in both groups. Marihuana smoke,
unlike cigarette smoke, causes bronchodilatation rather than bronchoconstriction and, unlike
opiates, does not cause central respiratory depression."

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• The effects of smoked marijuana on metabolism and respiratory control
Am Rev Respir Dis. 1978 Nov;118(5):885-91
https://www.ncbi.nlm.nih.gov/pubmed/367234

“In a placebo-controlled study of 8 subjects, smoking marijuana significantly increased

ventilation and hypercapnic ventilatory response. Peak effects occurred 15 min after smoking,
when ventilation increased from 7.4 +/- 0.39 (mean +/- SE) to 10.4 +/- 1.41 liter per min (P less
than 0.01), whereas hypercapnic ventilatory response, measured as the slope of the relationship
of ventilation to CO2, increased from 2.7 +/- 0.28 to 5.4 +/- 1.02 liter per min per mm Hg (P less
than 0.05). Blood pH, PCO2, and ventilatory response to hypoxia were unchanged. Changes in
ventilation usually parallel changes in metabolic rate. Smoked marijuana caused an increase in
metabolic rate that also peaked after 15 min. Pretreatment with propranolol completely abolished
the increase in hypercapnic ventilatory response, but did not affect the other changes. Thus,
smoked marijuana had stimulatory effects on metabolic rate, ventilation, and the ventilatory
response to CO2. The latter appears to be mediated by the beta sympathetic nervous system.”

• Ventilatory-depressant effects of opioids alone and in combination with cannabinoids in

rhesus monkeys
European Journal of Pharmacology Volume 833, 15 August 2018, Pages 94-99
https://www.sciencedirect.com/science/article/pii/S0014299918303108

“In summary, cannabinoid receptor agonists, which increase the potency of opioids to produce
antinociception, did not increase their potency to depress ventilation. Thus, the therapeutic
window is greater for opioids when they are combined with cannabinoid receptor agonists,
indicating a possible advantage for these drug mixtures in treating pain.”

• Pharmacotherapy of Apnea by Cannabimimetic Enhancement, the PACE Clinical Trial:

Effects of Dronabinol in Obstructive Sleep Apnea
Sleep, Volume 41, Issue 1, 1 January 2018, zsx184,
https://academic.oup.com/sleep/article/41/1/zsx184/4600041

“In comparison to placebo, dronabinol dose-dependently reduced AHI by 10.7 ± 4.4 (p = .02) and
12.9 ± 4.3 (p = .003) events/hour at doses of 2.5 and 10 mg/day, respectively. Dronabinol at 10
mg/day reduced ESS score by !3.8 ± 0.8 points from baseline (p < .0001) and by !2.3 ± 1.2
points in comparison to placebo (p = .05).”

Summary:
Marijuana not only allows patients to take fewer pills and lower doses, but as it is a mild
respiratory stimulant and bronchodilator, it increases the therapeutic window of opioids. In
short: MARIJUANA LOWERS THE RISK OF OPIOID OVERDOSES.

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 Marijuana and Opioid Reduction
• Cannabis Use Is Associated With Decreased Opiate Medication Use in a Retrospective
Cross-Sectional Survey of Patients With Chronic Pain
J. Pain Jun 2016; 17(6):739-44.
http://www.ncbi.nlm.nih.gov/pubmed/27001005

“Survey of 244 chronic pain patients found medical cannabis use associated with a 64% decrease
in opioid use, decreased number and side effects of medications, and an improved quality of
life.”

• Cannabinoid-opioid interaction in chronic pain

Clin Pharmacol Ther. 2011 Dec;90(6):844-51
https://www.ncbi.nlm.nih.gov/pubmed/22048225

“Cannabinoids and opioids share several pharmacologic properties and may act synergistically.
The potential pharmacokinetics and the safety of the combination in humans are unknown. We
therefore undertook a study to answer these questions. Twenty-one individuals with chronic pain,
on a regimen of twice-daily doses of sustained-release morphine or oxycodone were enrolled in
the study and admitted for a 5-day inpatient stay. Participants were asked to inhale vaporized
cannabis in the evening of day 1, three times a day on days 2-4, and in the morning of day 5.
Blood sampling was performed at 12-h intervals on days 1 and 5. The extent of chronic pain was
also assessed daily. Pharmacokinetic investigations revealed no significant change in the area
under the plasma concentration-time curves for either morphine or oxycodone after exposure to
cannabis. Pain was significantly decreased (average 27%, 95% confidence interval (CI) 9, 46)
after the addition of vaporized cannabis. We therefore concluded that vaporized cannabis
augments the analgesic effects of opioids without significantly altering plasma opioid levels. The
combination may allow for opioid treatment at lower doses with fewer side effects.”

• The Effect of Medicinal Cannabis on Pain and Quality-of-Life Outcomes in Chronic Pain:
A Prospective Open-label Study
Clin J Pain. 2016 Dec;32(12):1036-1043
https://www.ncbi.nlm.nih.gov/pubmed/26889611

“A total of 274 participants were approved for treatment; complete baseline data were available
for 206 (intent-to-treat), and complete follow-up data for 176 participants. At follow-up, the pain
symptom score improved from median 83.3 (95% confidence interval [CI], 79.2-87.5) to 75.0
(95% CI, 70.8-79.2) (P<0.001). The pain severity score (7.50 [95% CI, 6.75-7.75] to 6.25 [95%
CI, 5.75-6.75]) and the pain interference score (8.14 [95% CI, 7.28-8.43] to 6.71 [95% CI,
6.14-7.14]) improved (both P<0.001), together with most social and emotional disability scores.
Opioid consumption at follow-up decreased by 44% (P<0.001). Serious adverse effects led to
treatment discontinuation in 2 participants.”

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 Appendix: Marijuana’s History and Current Legal Status
- historical records show that marijuana has been used medicinally for at least 5000 years.
- from Japan to the Middle East, it was used for thousands of years, and entered Europe and the
United States in the 1850s, as the result of British expansion into India (where it is routinely used
still).
- It was prescribed by U.S. physicians until 1937, when it was banned by Congress due to stories
such as racial intermingling in southern jazz clubs. The AMA’s testified before Congress,
strongly opposing the decision.
- It was then made Schedule I in the CSA, despite the commission set up to schedule drugs
recommending that it not be scheduled.
- Hence, its legal history is the result not of medical science but of politics and racism.

- From the 1970s to 1990s, the federal government sponsored more than fifty billion dollars of
research to demonstrate the dangers of marijuana, and funding was dependent on confirming
what was expected. At the same time, the NIH sponsored research in other countries, most
notably in Israel, on its medical benefits. As a result, Israel legalized medical marijuana in 1992
(note that marijuana has a long history of use in Judaism, both medicinally and as part of
religious activities, ranging from orthodox approaches to the prescribed mitzvah of tikkun olam
to contemporary celebrations of Purim).

- California legalized medical marijuana in 1996, as did another 7 states as well as Canada by
2000. By 2010, 16 states legalized, and now we are at 31 states (plus D.C.) plus twenty-five
other countries. In fact, along with ten other states, recreational marijuana is legal in our nation’s
capitol.

- Oklahoma legalized medical marijuana June 26th, 2018 and began to issue medical marijuana
patient licenses August 25th. More than 5000 licenses have been issued as of September 15th and
following national averages, we will have roughly 100,000 licenses issued over the next eighteen
to twenty-four months.

With regard to the legality of prescribing opioids to card holders:

1) you do not need to sign a patient medical marijuana recommendation form. Patients can have
their primary care provider or another doctor sign it.
2) there is no state or federal law against recommending marijuana. Physicians are
constitutionally protected when they issue these recommendations (as established by Conat v.
Walters 2002).
3) the OBN has stated that they have no objection to physicians prescribing opioids to marijuana
card holders.
4) SB 1446 (Effective November 1st) requires pain management physicians to pursue strategies to
help patients reduce their opioid doses. The epidemiological data overwhelmingly supports that
marijuana legalization reduces opioid use; and likewise, the medical literature provides
significant evidence of safety and efficacy. SB 1446 thus offers pain management physicians a
reason for allowing their patients to use MJ in order to reduce their dosages.